Tuberculosis (TB) Fundamentals for

School Nurses June 9, 2015

Kristin Gall, RN, MSN/Pat Infield, RN-TB Program Manager Marsha Carlson, RN, BSN Two Rivers Public Health Department

Nebraska Department of Health and Human Services

Objectives

Identify the TB Disease Process, and TB

trends/statistics

Describe the role of the school nurse in

managing TB issues in the pediatric

population

Analyze a case review solution for a

pediatric case of TB

Transmission and Pathogenesis of TB

Caused by Mycobacterium tuberculosis (tubercle

bacillus)

Spread through the air by inhaled droplet nuclei

Prolonged contact needed for transmission

Transmission can occur from an infectious TB case

by coughing, sneezing, laughing, or singing

TB most common in lungs (85%), but can occur in

other parts of the body (extrapulmonary)

Tuberculosis (TB)

TB in Children TB is more prevalent in adults

In children, TB is more serious than in adults

Young children, especially under the age of 4, have difficulty fighting off infections & can have serious forms of TB if left untreated

Treating latent TB infection can prevent the child from getting active TB disease in the future

TB Infection vs. TB Disease

Symptoms of TB Disease

Prolonged cough (may produce sputum)*

Chest pain*

Hemoptysis*

Fever

Chills

Night sweats

Fatigue

Loss of appetite

Weight loss/failure to gain weight *commonly seen in cases of pulmonary TB

Infectiousness Children have few tubercle bacilli in lungs,

therefore, are rarely infectious

Children less than 12 years of age usually lack the pulmonary force to produce airborne bacilli

For a case of childhood TB infection, it is likely that an adolescent or adult transmitted TB bacilli to the child; it is important to find the source case

Window Therapy

Children younger than age five

Placed on preventive LTBI meds until second round of skin testing can rule out active TB

Recommendations for Skin Testing

The American Academy of Pediatrics recommends targeted TB skin testing only in areas of high TB prevalence

Routine skin testing does not need to be done in low prevalence areas

Consult with your school district and health department for local skin testing guidelines

School nurses may be required to administer skin tests or read results of a skin test for a physician

Tuberculin Skin Testing (TST) - 1

TST used for detection of TB infection

Use Mantoux method not multiple-puncture method (e.g. Tine test)

If a child has a documented history of a previously positive skin test, school nurse should inquire about history of treatment completion:

If no documented history of treatment completion is present, child should be referred to the health department

If documented treatment completion history is present, the child need not be skin tested nor chest X-rayed again; should be instructed to watch for signs and symptoms of TB in the future

Tuberculin Skin Testing (TST) Administration*

Use 5 TU purified protein derivative (PPD) tuberculin

Intradermally inject 0.1 cc of tuberculin into arm forming 6-10 mm wheal

Have child come back for reading 48-72 hours later

* detailed method can be found in Tuberculosis School Nurse

Handbook

Tuberculin Skin Testing (TST) Reading and Interpretation

Measure only transverse induration (hardness, not erythema (redness) or bruising)

Document result with a millimeter reading (not just as ‘negative’ or ‘positive’)

Use school district/health department guidelines for medical evaluation and referral for a positive result

Interferon Gamma Release Assay

Does not react to Bacille Calmette Guerin vaccine

Used in all instances a TST is utilized

Needs to be processed within 12 hours

Ok to use in children 5 and over

Not approved for use in patients with

immune problems

BCG Vaccine

BCG vaccine is used in parts of the world where TB is highly prevalent

It may cause a false-positive skin test result, however, there is no way to distinguish a false-positive from true infection

If a child has a history of having received BCG vaccine & has a positive skin test result, (s)he should be referred for a medical evaluation, as per school district/health department guidelines

Diagnosis of TB

Diagnosis of TB - 1

If a child has a positive skin test (s)he should have a chest X-ray and medical examination for symptoms of TB

If the chest X-ray is negative and the child is asymptomatic, the child should be evaluated for treatment of latent TB infection

Diagnosis of TB - 2

If chest X-ray and skin test are both positive and/or TB symptoms are present, sputum or other site specific specimen should be collected

Specimen smear results may show acid fast bacilli (TB-like bacilli)

True confirmation of TB is through culture (growing M. tuberculosis) from the specimen

TB Treatment If TB is suspected, prior to receiving TB culture

results, treatment must be initiated

There are four first-line TB drugs:

Isoniazid (INH)

Rifampin (RIF)

Pyrazinamide (PZA)

Ethambutol (EMB)

Usual Pediatric Treatment Regimens

Diagnosis Treatment

TB Infection INH – 9 Months

TB Disease

3 or 4 drugs

First 2 months – INH, RIF, PZA, EMB (add EMB if drug resistance is suspected)

Next 4 months – 2 most effective sensitive drugs (INH & RIF in pansensitive cases)

Multidrug resistant TB disease (resistance to at least INH & RIF)

Treat with sensitive drugs (varies) for at least 18 months

Directly Observed Therapy (DOT)

DOT is the watching of the ingestion of anti-TB medications by a trained outreach worker or healthcare worker

DOT cannot be administered by a family member

School-Based DOT School nurse can administer DOT in school

Clinician will provide regimen for nurse to follow

School nurse can give feedback to clinician on frequency of dosing that works well for child (medication must be given only once a day, but can vary the amount of times per week as per physician order)

School nurse can also provide feedback on child’s medical condition

Administering TB Medication in School -1

As with all medical conditions, there should be confidentiality surrounding taking medications

You cannot contract TB from administering medications to a child with TB, as an infectious child will not be sent to school

Administer medication in a private area at a time convenient to the child

Administering TB Medication in School - 2

Notify the physician of problems if the child:

Is absent for prolonged period of time

Is frequently missing doses of medication

Has side effects or adverse reactions

Has symptoms which do not improve or improve and then suddenly return

Challenges in Medication Administration - 1

School absences/vacations - make arrangements ahead of time

Have the child’s parent/guardian inform you directly of a pending absence

In case of absence/vacation see if health department can provide DOT

If you are absent, arrange for substitute nurse to administer medications

Challenges in Medication Administration - 2

“No show” for medications

Discretely, check if child is absent and then institute absentee plan

Avoid forgetfulness by choosing a convenient time for medication administration such as before school or lunchtime

Challenges in Medication Administration - 3

Difficulty swallowing medications

If you must, use food to mix medications with and vary food choices periodically

Use the smallest amount of food possible to mix medications in

Pills can be crushed and capsules can be opened and the contents mixed with food

Challenges in Medication Administration - 4

Lack of understanding and incentive

You should constantly reinforce the importance of taking anti-TB medications as prescribed

Refer concerns to the physician

Provide positive feedback and small rewards to the child for successfully completing medication

Challenges in Medication Administration - 5

Lack of time

Consider flexible scheduling so that children with varying medical needs can come for care at different times throughout the day

Prioritize certain children’s regimens that cannot be adjusted easily

Challenges in Medication Administration - 6

Lack of time, cont’d

Although TB medications are given only once a day, they should be given at the same time each day and dose cannot be split

With clinician order, intermittent therapy may be possible (administering medication 2-3x per week as opposed to daily)

TB Among the Foreign Born

Case Review

8 y.o. Hispanic female

Spends summers in Mexico

Student

Lives with parents and siblings

Clinical Presentation

8/12 Right side lymph node enlargement

Removed

Tested negative for m TB

Did not respond to azithroymycin

8/13 other lymph nodes removed

Tested for M TB

Tested + for m Bovis

Clinical Assessment

No S/S except Right enlarged lymph node

TST: 7 mm (no IGRA done)

Chest x-ray: opacity seen at upper L mediastinum (not suspicious TB)

Sputum: negative

Should we do contact investigation?

DOT and F/U

INH, RIF, EMB started 9-6-13

DOT 2x weekly (no breaks in therapy)

21.4 kg (9-6-13)

23.6 kg (7-15-14)

Caring for child with TB is an important responsibility whether the child has infection or disease. The school nurse’s role is important in controlling TB rates in this country.

Nebraska TB Program Pat Infield, RN, TB Program Manager

Phone: (402) 471-6441 Email: pat.infield@nebraska.gov

Kristin Gall, RN, TB Education Focal Point Phone: (402) 471-1372 Email: kristin.gall@nebraska.gov Or Your Local Health Department

School Nurse Handbook -Rutgers Global Tuberculosis Institute, 2013

Resources

School Nurse Handbook

http://globaltb.njms.rutgers.edu/products/documents/School%20Nurse%20Handbook/School%20Nurse%20Handbook%20-%20single%20page.pdf